OLR Bill Analysis

sHB 5296



This bill establishes a uniform, statutory definition of medical necessity that the Department of Social Services (DSS) must see when administering its medical assistance programs. Currently, there are two definitions that are used, one in the State-Administered General Assistance (SAGA) program and another in the other DSS medical assistance programs.

The bill prohibits clinical guidelines from being used as the basis for final medical necessity determinations.

If DSS medical assistance program beneficiaries are denied services based on medical necessity, the bill requires that they be notified that they can request a copy of the specific guideline or criteria, other than the definition, that were considered.

Finally, the bill permits DSS to repeal any regulatory definition that is inconsistent with the bill's definition. And it requires the DSS commissioner to implement the bill while in the process of adopting regulations.

EFFECTIVE DATE: July 1, 2010


New Definition

The bill establishes a statutory definition of “medically necessary” and “medical necessity” in DSS' medical assistance programs. The definition is:

“Those health services required to prevent, identify, diagnose, treat, rehabilitate, or ameliorate an individual's medical condition, including mental illness, or its effects, in order to attain or maintain the individual's achievable health and independent functioning, provided such services are:

1. consistent with generally accepted standards of medical practice that are defined as standards that are based on (a) credible scientific peer-reviewed medical literature that is generally recognized by the relevant medical community, (b) recommendations of a physician-specialty society, (c) the views of physicians practicing in relevant clinical areas, and (d) any other relevant factors;

2. clinically appropriate in terms of type, frequency, timing, site, extent, and duration and considered effective for the individual's illness, injury, or disease;

3. not primarily for the convenience of the individual, the individual's health care provider, or other health care providers;

4. not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual's illness, injury, or disease; and

5. based on an assessment of the individual and his or her medical condition.

Current Definitions

DSS currently uses two medical necessity and medically necessary definitions in its medical assistance programs, neither of which is in statute. The State-Administered General Assistance (SAGA) medical assistance program regulations use the following definition:

“Health services required to prevent, identify, diagnose, treat, rehabilitate, or ameliorate a health problem or its effects, or to maintain health and functioning, provided such services are:

1. consistent with generally accepted standards of medical practice,

2. clinically appropriate in terms of type, frequency, timing, site, and duration;

3. demonstrated through scientific evidence to be safe and effective and the least costly among similarly effective alternatives, where adequate scientific evidence exists;  and

4. efficient in regard to the avoidance of waste and refraining from provision of services that, on the basis of the best available scientific evidence, are not likely to produce benefit.

DSS uses the following definition of medical necessity (also “medically necessary”) in the Medicaid fee-for-service, HUSKY, Charter Oak Health Plan, and State Medical Assistance for Noncitizens programs:

“Health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition or prevent a medical condition or prevent a medical condition from occurring.

Use of Clinical Guidelines

Under the bill, clinical and medical policies, clinical criteria, or any other generally accepted clinical practice guidelines used to assist in evaluating the medical necessity of a requested health service may be used solely as a guideline and cannot be the basis for a final medical necessity determination.

When Service Denied Based on Medical Necessity

The bill provides that if a request for authorization of services is denied based on medical necessity, the individual must be notified that, upon request, DSS will provide a copy of the specific guideline or criteria, or portion thereof, other than the medical necessity definition that DSS or an entity acting on its behalf (e. g. , utilization review company) considered when making its determination.

Repealing Existing Regulations and Implementing Change While in Process of Adopting New Regulations

The bill permits DSS to amend or repeal any regulatory definition, including the definitions of “medical appropriateness” and “medically appropriate,” used in administering the medical assistance programs that are inconsistent with the new statutory definition.

The bill requires the commissioner to implement policies and procedures to carry out the definition change while in the process of adopting them in regulation. He must publish notice of intent to adopt the regulations in the Connecticut Law Journal within 20 days of implementation. These policies and procedures are valid until the final regulations are adopted.


Related Bill

SB 492 ( 53), passed by the Senate on March 27, 2010, contains identical provisions.

Definition of Medical Appropriateness and Medically Appropriate

State regulations define these terms as “health care that is provided in a timely manner and meet professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective alternative treatments or diagnostic modalities” (Conn. Agency Regs. , Title 17b).


Human Services Committee

Joint Favorable Substitute